Compositions and methods for keto stacking with beta-hydroxybutyrate and acetoacetate

ABSTRACT

Compositions for delivering ketone bodies to a subject include one or more beta-hydroxybutyrate salts, one or more acetoacetate salts, beta-hydroxybutyric acid, and optionally acetoacetic acid. The compositions may optionally include one or more ketone body esters, such as one or more beta-hydroxybutyrate esters and/or one or more acetoacetate esters. An example composition contains about 2% to about 98% on a molar basis of the one or more beta-hydroxybutyrate salts and the one or more acetoacetate salts, about 2% to about 98% on a molar basis of the beta-hydroxybutyrate free acid and optionally the acetoacetate free acid, and optionally about 2% to about 98% on a molar basis of one or more ketone body esters.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.17/157,000, filed Jan. 25, 2021, which is a continuation of U.S. patentapplication Ser. No. 16/381,202, filed Apr. 11, 2019, now U.S. Pat. No.10,925,843, which claims the benefit of U.S. Provisional PatentApplication No. 62/659,564, filed Apr. 18, 2018, which are incorporatedherein by reference in their entirety.

BACKGROUND 1. Field of the Invention

Disclosed herein are compositions including effective ratios ofbeta-hydroxybutyrate and acetoacetate, stacked compositions includingtwo or more different forms of ketone bodies, and methods of using thesame for producing elevated blood levels of ketone bodies in a mammal.

2. Related Technology

In periods of fasting, extreme exercise, and/or low carbohydrateconsumption, glucose and glycogen stores in the body are rapidly usedand can become quickly depleted. Failure to replenish glucose stores asthey become depleted causes the body to metabolically shift to thecreation of ketone bodies for energy (“ketosis”). Ketone bodies can beused by cells of the body as a fuel to satisfy the body's energy needs,including the brain and heart. During prolonged fasting, for example,blood ketone levels can increase to 2-3 mmol/L or more. It isconventionally understood that when blood ketones rise above 0.5 mmol/L,the heart, brain and peripheral tissues are using ketone bodies (e.g.,beta-hydroxybutyrate and acetoacetate) as the primary fuel source. Thiscondition is referred to as ketosis. Between 1.0 mmol/L and 3.0 mmol/Lthe condition is called “nutritional ketosis.”

Upon transitioning into ketosis, or in other words, during ketogenicmetabolism in the liver, the body uses dietary and bodily fats as aprimary energy source. Consequently, once in ketosis, one can induceloss of body fat by controlling dietary fat intake and maintaining lowcarbohydrate to sustain ketosis.

While in ketosis, the body is in ketogenesis and is essentially burningfat for its primary fuel. The body cleaves fats into fatty acids andglycerol and transforms fatty acids into acetyl CoA molecules, which arethen eventually transformed through ketogenesis into the water-solubleketone bodies beta-hydroxybutyrate “β-hydroxybutyrate” or“beta-hydroxybutyrate”), acetoacetate, and acetone in the liver.beta-hydroxybutyrate and acetoacetate are the ketone bodies used by thebody for energy while acetone is removed as a by-product of ketogenesis.

The metabolism of ketone bodies is associated with several beneficialeffects, including anticonvulsant effects, enhanced metabolism by thebrain, neuroprotection, muscle sparing properties, and improvedcognitive and physical performance. Science-based improvements inefficiency of cellular metabolism, managed through ketonesupplementation, can have beneficial impacts on physical, cognitivehealth, and psychological health, and a long-term impact on health withrespect to the common avoidable diseases such as obesity, cardiovasculardisease, neurodegenerative diseases, diabetes, and cancer.

Despite the many health advantages of pursuing a ketogenic diet orlifestyle and maintaining a state of nutritional ketosis, there remainsignificant barriers to pursuing and maintaining a ketogenic state. Oneof these barriers is the difficulty of transitioning into a ketogenicstate. The fastest endogenous way to enter ketosis is by depletingglucose stores in the body through fasting combined with exercise. This,however, is physically and emotionally demanding and can be extremelychallenging even for the most motivated and disciplined.

Additionally, the transition into ketosis is often accompanied byhypoglycemia, which can cause lethargy and light-headedness in many,resulting in an uncomfortable physiological and mental state commonlyreferred to as “low-carb flu.” In addition, many people experience downregulation in their metabolism as the body goes into “energy-saving”mode. Some suggest that these transitory symptoms may last as long astwo to three weeks. During this transition period, if any meal or snackcontaining carbohydrates over a restricted amount is consumed, there isan immediate termination of ketogenesis, exiting the body from a stateof ketosis, as the body shifts back to glucose as its primary fuel, andthe transition into ketosis must begin anew.

If a subject is successful in establishing ketosis, the act ofsustaining ketosis is likewise difficult, if not more difficult, due tothe need to maintain a rigid dietary ratio of carbohydrates and proteinto fats.

To overcome the difficulties associated with inducing ketosis viafasting and exercise, methods of inducing ketosis through directadministration of ketone bodies have been proposed. While some of thesemay work to induce ketosis in an individual, several limitations remain.In particular, while relatively brief spikes in blood ketone body levelsmay be achieved, such spikes tend to wane much faster than desired.Accordingly, there is a long felt and continuing need for compositionsand methods capable of promoting and maintaining ketosis over longperiods of time.

BRIEF SUMMARY

Disclosed herein are compositions and methods for promoting andmaintaining ketosis. Exogenous ketone bodies (i.e., beta-hydroxybutyrateand acetoacetate) may be provided in three general forms: 1) salt forms,2) ester forms, and 3) free acid forms (i.e., beta-hydroxybutyric acidand/or acetoacetic acid). Each of these forms provides certain benefitsbut can have undesirable side effects.

The compositions described herein may be provided as a “stacked” mixturecombining at least two of these forms. Such stacked compositions canbeneficially limit the occurrence and/or severity of undesirableside-effects and/or can permit administration of higher doses ofexogenous ketone bodies. Stacked compositions therefore permit deliveryof substantially higher amounts of exogenous ketone bodies whilereducing or minimizing detrimental effects of delivering too much of onetype of exogenous ketone body.

Moreover, a stacked composition can provide higher and/or more sustainedlevels of ketone bodies in the blood as compared to an otherwise similaramount provided in a single form. For example, a stacked formulation canbe tailored to provide a more preferable or more optimized releaseprofile, such as one that combines the benefits of more rapid onset withthe benefits of a more extended release, and/or one that provides anoverall greater pharmacokinetic area under the curve (AUC). Stackedcompositions therefore provide for timed delivery or availability ofketone bodies, which provides for more even blood concentration ofketone bodies and a significantly longer delivery “tail” of exogenousketone bodies, such as 1-8 hours after consuming the stackedcomposition.

Stacked compositions permit the selection and tailoring of differentratios and combinations of various forms of beta-hydroxybutyrate andacetoacetate to address different nutritional and/or health needs ofdifferent individuals or groups. For example, different ratios and/orcombinations of different types of exogenous ketone bodies can beselected to address different conditions based on a person's age,gender, state of health, disease condition, and the like.

Embodiments disclosed herein are directed to ketogenic compositionsformulated for inducing and sustaining ketosis in a subject. An examplecomposition includes a mixture of beta-hydroxybutyrate and acetoacetate,wherein the beta-hydroxybutyrate is included in an amount of about 55%to about 95% of the mixture and the acetoacetate is included in anamount of about 5% to about 45% of the mixture. Thebeta-hydroxybutyrate/acetoacetate mixture may be combined with adietetically or pharmaceutically acceptable carrier.

As explained in more detail below, exogenous acetoacetate can beutilized for energy during ketolysis with less reduction in thesubject's available NAD⁺ as compared to exogenous beta-hydroxybutyrate.Certain compositions described herein are therefore formulated toinclude proportionally sufficient acetoacetate to limit the undesirablereduction in available NAD⁺ as compared to a similar dose ofbeta-hydroxybutyrate only or a similar dose of beta-hydroxybutyrate withinsufficient acetoacetate.

At the same time, however, too much acetoacetate relative tobeta-hydroxybutyrate can lead to other undesirable side effects.Excessive acetoacetate is associated with high levels of acetone in theblood. Much of this acetone is expelled from the subject's body throughthe breath, resulting in the telltale and often unpleasant “keto breath”associated with a subject in ketosis.

Disclosed compositions are beneficially formulated to balance thedifferent benefits and limitations of beta-hydroxybutyrate andacetoacetate by including proportions of each that effectively promoteand/or sustain ketosis, comparatively limit the reduction in availableNAD⁺ in the subject, and limit excess levels of acetone in the blood.Regulating the amount of each separate ketone body component and/orproviding different stacked forms of exogenous ketone bodiesbeneficially allows for tailored compositions optimized for particularapplication needs or preferences.

Ketogenic compositions described herein may be useful as one or more of:weight loss supplement; treatment for high blood glucose or type IIdiabetes; brain tonic; athletic performance enhancer; preventativeagainst metabolic dysfunction, mitochondrial defect, and/or insulinresistance; adjunct to a ketogenic diet; anti-aging supplement; andother uses associated with improved metabolic health.

In one embodiment, a ketogenic composition includes at least twoseparate exogenous ketone bodies selected from the group consisting of:(i) a beta-hydroxybutyrate salt; (ii) an acetoacetate salt; (iii) abeta-hydroxybutyrate ester; (iv) an acetoacetate ester; (v) abeta-hydroxybutyrate free acid (i.e., beta-hydroxybutyric acid); and(vi) an acetoacetate free acid (i.e., acetoacetic acid). A stackedketone body composition preferably includes a combination of ketone bodycompounds selected from (i) through (vi) such that there are at leasttwo of: (A) one or more ketone body salts; (B) one or more ketone bodyesters; and (C) one or more ketone body free acids.

In addition, because beta-hydroxybutyrate has a chiral center, any ofthe salt, ester, and acid forms of beta-hydroxybutyrate can beR-beta-hydroxybutyrate, S-beta-hydroxybutyrate, a racemic mixture ofR,S-beta-hydroxybutyrate, or a mixture enriched withR-beta-hydroxybutyrate or S-beta-hydroxybutyrate. R-beta-hydroxybutyrateis the endogenous form of beta-hydroxybutyrate produced by the body,while S-beta-hydroxybutyrate can be converted to R-beta-hydroxybutyrate,such as by enzymatic conversion to acetoacetate, which has no chiralcenter, and then to R-beta-hydroxybutyrate. BecauseR-beta-hydroxybutyrate is the endogenous form, it is more rapidlyutilized by the body. Conversely, S-beta-hydroxybutyrate provides forslower, delayed available of available ketone bodies because it mustfirst be converted to R-beta-hydroxybutyrate before it can be used asenergy. Nevertheless, S-beta-hydroxybutyrate may have other benefitsunrelated to energy, such as signaling. In view of the foregoing,stacked compositions can also include different amounts or rations ofR-beta-hydroxybutyrate and S-beta-hydroxybutyrate.

Additional features and advantages will be set forth in part in thedescription that follows, and in part will be obvious from thedescription, or may be learned by practice of the embodiments disclosedherein. It is to be understood that both the foregoing brief summary andthe following detailed description are exemplary and explanatory onlyand are not restrictive of the embodiments disclosed herein or asclaimed.

BRIEF DESCRIPTION OF DRAWINGS

FIG. 1 schematically illustrates some of the metabolic pathways ofketosis, showing ketogenesis in the liver and ketolysis in peripheraltissues such as muscle;

FIG. 2A illustrates higher levels of exogenous ketone bodies that may beadministered when using a “stacked” dose of at least two different formsof exogenous ketone bodies as compared to single forms of the exogenousketone body;

FIG. 2B illustrates expected relative rates of undesirable side-effectsresulting from treatment with various formulations of exogenous ketonebodies, where a “triple stack” formulation comprising each of 1) a saltform of an exogenous ketone body, 2) an ester form of an exogenousketone body, and 3) a free acid form of an exogenous ketone body (i.e.,beta-hydroxybutyric acid and/or acetoacetic acid) is expected to allowfor administration of a greater amount of exogenous ketone bodies and/orless occurrence or intensity of side-effects as compared to a “doublestack” comprising only two such forms of exogenous ketone bodies, andwhere both the triple stack and double stack formulations are expectedto allow for administration of a greater amount of exogenous ketonebodies and/or less occurrence or intensity of side-effects as comparedto administration of a “single form” comprising only a single such formof an exogenous ketone body; and

FIG. 3 compares expected release profiles of stacked compositions (e.g.,R-beta-hydroxybutyrate comprising each of the free acid, salt, and esterforms and R,S-beta-hydroxybutyrate) to each of the free acid, salt, andester single forms, illustrating that stacked compositions may providean overall release profile that is extended and has a larger area underthe curve (AUC).

DETAILED DESCRIPTION I. Definitions

The compound “beta-hydroxybutyrate,” also known as (3-hydroxybutyrate,3-hydroxybutyrate, beta-hydroxybutyrate, or beta-hydroxybutyrate, is thedeprotonated form of beta-hydroxybutyric acid, which is ahydroxycarboxylic acid having the general formula CH₃CH₂OHCH₂COOH. Thedeprotonated form present at typical biological pH levels isCH₃CH₂OHCH₂COO⁻. The general chemical structure shown below representsbeta-hydroxybutyrate compounds that may be utilized in the disclosedcompositions:

-   -   where,    -   X can be hydrogen, metal ion, amino cation such as from an amino        acid, alkyl, alkenyl, aryl, or acyl.

When X is a hydrogen, the compound is beta-hydroxybutyric acid. When Xis a metal ion or an amino cation, the compounds is abeta-hydroxybutyrate salt. When X is alkyl, alkenyl, aryl, or acyl, thecompounds is a beta-hydroxybutyrate ester. The foregoing compounds canbe in any desired physical form, such as crystalline, powder, solid,liquid, solution, suspension, or gel.

Beta-hydroxybutyrate may be utilized by a patient's body as an energysource during instances of low glucose levels in the subject or when apatient's body is supplemented with a usable form ofbeta-hydroxybutyrate. Although not technically a “ketone”, one of skillin the art will recognize that beta-hydroxybutyrate, in the context ofketosis, is commonly referred to as a “ketone body”.

The beta-hydroxybutyrate compound can be provided as a racemic mixtureof enantiomers, or R,S-beta hydroxybutyrate (also known as DL-betahydroxybutyrate), which can be made synthetically. In humans, theenantiomer R-beta-hydroxybutyrate (“D-3-hydroxybutyrate,” “D-betahydrobutyrate,” or “D-beta-hydroxybutyrate”) is synthesized in the liverfrom acetoacetate, the first ketone produced in the fasting. Therefore,it may be desirable to provide beta-hydroxybutyrate as the R-enantiomerto increase potency, either enriched relative to S-beta-hydroxybutyrate(“L-3-hydroxybutyrate,” “L-beta hydrobutyrate,” or“L-beta-hydroxybutyrate”) or in purified form isolated fromS-beta-hydroxybutyrate.

Alternatively, it may be desirable to provide beta-hydroxybutyrate asthe S-enantiomer, either enriched relative to R-beta-hydroxybutyrate orin purified form isolated from R-beta-hydroxybutyrate.S-beta-hydroxybutyrate may be associated with one or more of: increasedendogenous production of R-beta-hydroxybutyrate and acetoacetate;endogenous conversion of the S-beta-hydroxybutyrate into one or both ofR-beta-hydroxybutyrate and acetoacetate; endogenous conversion of theS-beta-hydroxybutyrate into fatty acids and sterols; prolonged ketosis;metabolism of the S-beta-hydroxybutyrate independent of conversion toR-beta-hydroxybutyrate and/or acetoacetate; increased fetal development;increased growth years; reduced endogenous production of acetone duringketosis; signaling by the S-beta-hydroxybutyrate that modulatesmetabolism of R-beta-hydroxybutyrate and glucose; antioxidant activity;and production of acetyl-CoA.

Administering R-beta-hydroxybutyrate, the endogenous form, results inattaining relatively rapid elevated ketosis, while administeringS-beta-hydroxybutyrate, which must first be converted to the R form,provides slower and more sustained ketosis. The different enantiomersmay therefore be combined in different proportions to tailor a desiredtime release profile according to particular application needs orpreferences.

The compound “acetoacetate” is the deprotonated form of acetoaceticacid, which is a carboxylic acid having the formula CH₃COCH₂COOH. Thedeprotonated form present at typical biological pH levels is thereforeCH₃COCH₂COO⁻. As with beta-hydroxybutyrate, acetoacetate may be utilizedas an energy source during ketosis. The following general chemicalstructure represents acetoacetate compounds that may be utilized in thedisclosed compositions (stereoisomers thereof may also be utilized):

-   -   where,    -   X can be hydrogen, metal ion, amino cation, such as from an        amino acid, alkyl, alkenyl, aryl, or acyl.

When X is a hydrogen, the compound is acetoacetic acid. When X is ametal ion or an amino cation, the compounds is an acetoacetate salt.When X is alkyl, alkenyl, aryl, or acyl, the compounds is anacetoacetate ester. The foregoing compounds can be in any desiredphysical form, such as crystalline, powder, solid, liquid, solution,suspension, or gel.

The beta-hydroxybutyrate and acetoacetate compounds described above maybe collectively referred to herein as “ketone bodies,” “exogenous ketonebodies,” a “ketone body component,” or “exogenous ketones.”

The terms “stacked composition,” “keto-stack,” “stack,” “ketone bodystack,” variations thereof, and the like are used herein to refer to acomposition including at least two separate exogenous ketone bodiesselected from the group consisting of: (i) a beta-hydroxybutyrate salt;(ii) an acetoacetate salt; (iii) a beta-hydroxybutyrate ester; (iv) anacetoacetate ester; (v) a beta-hydroxybutyrate free acid (i.e.,beta-hydroxybutyric acid); and (vi) an acetoacetate free acid (i.e.,acetoacetic acid).

Compounds (i) and (ii) represent different forms of “ketone body salts.”Compounds (iii) and (iv) represent different forms of “ketone bodyesters.” And compounds (v) and (vi) represent different forms of “ketonebody free acids.” A stacked ketone body composition preferably includesa combination of ketone body compounds selected from (i) through (vi)such that there are at least two of: (A) one or more ketone body salts;(B) one or more ketone body esters; and (C) one or more ketone body freeacids.

In at least some instances, the particular exogenous ketone body (i.e.,beta-hydroxybutyrate or acetoacetate) is referred to as the “ketone bodycomponent” while the particular salt, ester, or free acid portion isreferred to as the “carrier component.” For example, a sodiumbeta-hydroxybutyrate compound utilizes sodium as the carrier componentand beta-hydroxybutyrate as the ketone body component, acetoacetic acidutilizes hydrogen as the carrier component and acetoacetate as theketone body component, and a methyl beta-hydroxybutyrate utilizes amethyl group as the carrier component and beta-hydroxybutyrate as theketone body component. The ester and/or salt forms of ketone bodies canbe thought of as “carriers” for the acid form because they reduceacidity and harshness as compared to pure acid forms.

Some embodiments, in particular those that include a free acid form ofan exogenous ketone body, may also include a “stabilizer” that functionsto provide the exogenous ketone body in a more administrable form. Forexample, beta-hydroxybutyric acid and/or acetoacetic acid may bepartially neutralized using a strong or weak base, such as an alkali oralkaline earth metal hydroxide, carbonate, or bicarbonate, basic aminoacid, and the like. Following such a partial neutralization, thesolution will also include a “salt” form as defined herein. But wherethe neutralization is only partial, and a certain molar excess of H⁺ions remains present, the solution will also include a proportion of thefree acid form.

Some embodiments combine at least one beta-hydroxybutyrate compound withat least one acetoacetate compound.

Some embodiments optionally include a supplemental source of ketone bodyprecursors in the form of fatty acids or esters thereof. A typical esterform of fatty acids is a mono-, di-, or triglyceride. Preferred forms offatty acids and their esters are medium chain fatty acids, though shortand/or long chain fatty acids and their esters may also be utilized.Providing a supplemental source of ketone body precursors canbeneficially extend and/or elevate the effects of ketosis. That is, suchsupplemental sources can ensure that the body has sufficient “reserves”on hand for starting and maintaining ketosis in conjunction with theadministered exogenous ketone bodies.

Unless otherwise specified, the term “salt” does not mean or imply anyparticular physical state, such as a crystalline, powder, other solidform, dissolved in water to form a liquid solution, dispersed in aliquid to form a suspension, or gel. A salt can be formed in solution,such as by at least partially neutralizing beta-hydroxybutyric acidand/or acetoacetic acid with a strong or weak base, such as an alkali oralkaline earth metal hydroxide, carbonate, or bicarbonate, basic aminoacid, and the like.

Exemplary salt forms include sodium, potassium, calcium, and magnesiumsalts. Some embodiments include one or more transition metal salts.Transition metal cations suitable for use as part of a salt includelithium, chromium, manganese, cobalt, copper, zinc, iron, (e.g., as aniron II or iron III cation), molybdenum, and selenium. Other suitablesalt forms include cations of amino acids or their derivatives, such asarginine, lysine, histidine, ornithine, creatine, agmatine, andcitrulline. Suitable ester forms include mono-esters of ethanol,mono-esters of 1-propanol, mono-esters of 1,3-propanediol, di-esters of1,3-propanediol, mono-esters of S-1,3-butanediol, di-esters of1,3-butanediol, mono-esters of glycerin, di-esters of glycerin, andtri-esters of glycerin. 1,3-butanediol is a metabolicbeta-hydroxybutyrate precursor that may be additionally or alternativelybe utilized as a source of beta-hydroxybutyrate and/or acetoacetatecompounds.

As used herein, “subject” or “patient” refers to mammals, includinghumans and other primates. The subject may be any mammal requiringmetabolic therapy, treatment, or prophylaxis, or any mammal suspected ofrequiring metabolic therapy, treatment, or prophylaxis. Prophylaxismeans that regiment is undertaken to prevent a possible occurrence, suchas where a high risk of diabetes or other metabolic disorder isidentified. “Patient” and “subject” are used interchangeably herein.

The term “unit dose” refers to a dosage form that is configured todeliver a specified quantity or dose of composition or componentthereof. Example dosage forms include, but are not limited to, tablets,capsules, powders, food products, food additives, beverages, beverageadditives, candies, suckers, pastilles, food supplements, sprays,injectables, and suppositories. Such dosage forms may be configured toprovide a full unit dose or fraction thereof (e.g., ½, ⅓, or ¼ of a unitdose).

Another dosage form that can be used to provide a unit dose ofcomposition or component thereof is a unit dose measuring device, suchas a cup, scoop, syringe, spoon, or colonic irrigation device, which isconfigured to hold therein a measured quantity of composition equaling afull unit dose or fraction thereof (e.g., ½, ⅓, or ¼ of a unit dose).For example, a bulk container, such as a carton, box, can, jar, bag,pouch, bottle, jug, or keg, containing several unit doses of composition(e.g., 5-250 or 10-150 unit doses) can be provided to a user togetherwith a unit dose measuring device that is configured to provide a unitdose, or fraction thereof, of composition or component thereof.

A kit for use in providing a composition as disclosed herein in bulkform, while providing unit doses of the composition, may comprise a bulkcontainer holding therein a quantity of composition and a unit dosemeasuring device configured to provide a unit dose, or fraction thereof,of composition or component thereof. One or more unit dose measuringdevices may be positioned inside the bulk container at the time of sale,attached to the outside of the bulk container, prepackaged with the bulkcontainer within a larger package, or provided by the seller ormanufacture for use with one or multiple bulk containers.

The kit may include instructions regarding the size of the unit dose, orfraction thereof, and the manner and frequency of administration. Theinstructions may be provided on the bulk container, prepackaged with thebulk container, placed on packaging material sold with the bulkcontainer, or otherwise provided by the seller or manufacturer (e.g., onwebsites, mailers, flyers, product literature, etc.) The instructionsfor use may include a reference on how to use the unit dose measuringdevice to properly deliver a unit dose or fraction thereof. Theinstructions may additionally or alternatively include a reference tocommon unit dose measuring devices, such as spoons, spatulas, cups, andthe like, not provided with the bulk container (e.g., in case theprovided unit dose measuring device is lost or misplaced). In such case,a kit may be constructed by the end user when following instructionsprovided on or with the bulk container, or otherwise provided by theseller regarding the product and how to properly deliver a unit dose ofcomposition, or fraction thereof.

“Ketosis” as used herein refers to a subject having blood ketone levelswithin the range of about 0.5 mmol/L to about 16 mmol/L. Ketosis mayimprove mitochondrial function, decrease reactive oxygen speciesproduction, reduce inflammation and increase the activity ofneurotrophic factors. “Keto-adaptation” as used herein refers toprolonged nutritional ketosis (>1 week) to achieve a sustainednonpathological “mild ketosis” or “therapeutic ketosis,” or it denotesan altered metabolism in which fat becomes the predominant energysource, consequently shifting the body from a state of fat storage to astate of fat oxidation.

The term “medium chain triglycerides” (MCT) refers to molecules having aglycerol backbone attached to three medium chain fatty acids. Mediumchain fatty acids range from 6 to 12 carbon atoms in length. Exemplaryfatty acids are caprylic acid, also known as octanoic acid, comprising 8carbon molecules, and capric acid, also known as decanoic acid,comprising 10 carbon molecules. Because MCTs are ketone body precursors,including one or more MCTs may provide an additional source for theproduction of ketone bodies independent of the beta-hydroxybutyrate andacetoacetate compounds, thus helping to promote sustained elevation ofketone levels to a desired therapeutic level.

The term “short chain triglycerides” (SCT) refers to molecules similarto MCT molecules but with short chain fatty acids (6 carbon atoms orless in length, such as 5 carbon atoms or less) attached to the glycerolbackbone. These can be provided in the form of mono-, di-, andtriglycerides, other esters, salts, or free acids.

The term “long chain triglycerides” (LCT) refers to molecules similar toMCT molecules but with long chain fatty acids (12 carbon atoms or morein length, such as 13 carbon atoms or more) attached to the glycerolbackbone.

Examples of short chain fatty acids include acetic acid, propionic acid,butyric acid, isobutyric acid, valeric acid, isovaleric acid, andcaproic acid. Examples of medium chain fatty acids include caprylicacid, capric acid, and lauric acid. Examples of saturated long-chainfatty acids include myristic acid, palmitic acid, stearic acid,arachidic acid, behenic acid, lignoceric acid, and cerotic acid.

The term “administration” or “administering” is used herein to describethe process in which the ketogenic compositions are delivered to asubject. The composition may be administered in various ways includingoral, intragastric, or parenteral (referring to intravenous andintra-arterial and other appropriate parenteral routes), among others.

II. Balancing Beta-Hydroxybutyrate and Acetoacetate

The administration of a combined beta-hydroxybutyrate/acetoacetateketogenic composition results in elevated and sustained blood levels ofketone bodies, thereby exploiting the metabolic and physiologicaladvantages of sustained ketosis. Raising the levels of ketone bodies inthe blood to replicate the components of ketogenesis in a subjectprovides the subject with greater flexibility in diet options ascompared to a method that aims to induce and sustain ketosis based ondiet alone (e.g., based on fasting and/or limited carbohydrate intake).For example, a subject that has been administered appropriate amounts ofbeta-hydroxybutyrate and acetoacetate will be able to eat higher levelsof carbohydrate or sugar-based food without jeopardizing their ketogenicstate and shifting back into a glucose-based metabolic state, thusallowing them a much easier pathway to sustaining ketosis without therisk of metabolic confusion through toggling between glycolysis andketosis.

Examples of beneficial effects of increased ketone body level in asubject include one or more of appetite suppression, weight loss, fatloss, reduced blood glucose level, improved mental alertness, increasedphysical energy, improved cognitive function, reduction in traumaticbrain injury, reduction in effect of diabetes (e.g., type II diabetes),improvement of neurological disorder (e.g., ALS, Alzheimer's,Parkinson's), reduction of cancer, reduction of inflammation,anti-aging, anti-glycation, reduction in epileptic seizer, improvedmood, increased strength, increased muscle mass, or improved bodycomposition.

Further, such administration facilitates easier transitioning into aketogenic state while reducing or eliminating the detrimental effectstypically associated with entering ketosis, often referred to as the“keto flu,” a very undesirable effect and often high-level deterrentfrom entering into a ketogenic advantaged state.

Embodiments disclosed herein provide a therapeutically effective amountof a combined beta-hydroxybutyrate/acetoacetate composition.Beneficially, the beta-hydroxybutyrate/acetoacetate composition isformulated to provide biologically balanced proportions ofbeta-hydroxybutyrate and acetoacetate in order to optimize the inductionand/or sustainment of a ketogenic state in the user. For example, thecombined beta-hydroxybutyrate/acetoacetate embodiments disclosed hereinare capable of more effectively inducing and/or sustaining ketosis in amammal as compared to an otherwise similar dosage regimen ofbeta-hydroxybutyrate alone or acetoacetate alone. Likewise, certain ofthe combined beta-hydroxybutyrate/acetoacetate embodiments disclosedherein are capable of more effectively inducing and/or sustainingketosis in a mammal as compared to a composition that includes someunspecified amount of acetoacetate (likely some trivial amount).

FIG. 1 schematically illustrates the interplay between ketogenesis andketolysis. Ketogenesis occurs in the liver, where a combination ofcatabolic processes breaks down amino acids, fatty acids, and/orglycogen to generate the ketone bodies acetoacetate andbeta-hydroxybutyrate. The majority of these ketone bodies will typicallybe produced through fatty acid oxidation.

Although beta-hydroxybutyrate is the more reduced compound, bothbeta-hydroxybutyrate and acetoacetate are passed into the bloodstreamand delivered to peripheral tissues to be used as an energy source. Asshown, acetoacetate may be directly utilized in the TCA cycle (i.e.,citric acid cycle), whereas beta-hydroxybutyrate is first oxidized byNAD⁺ into acetoacetate before the resulting acetoacetate is incorporatedinto the TCA cycle.

With reference again to FIG. 1 , the benefits of the combinedbeta-hydroxybutyrate/acetoacetate compositions described herein will beexplained, in particular with regards to the benefits of NAD⁺ sparing.When a subject is in ketosis, the energy profile is already favorablefor NAD⁺ sparing as compared to when glucose is primarily used forenergy. Stacking the separate ketone body componentsbeta-hydroxybutyrate and acetoacetate can beneficially further spareNAD⁺, as explained below.

As shown, during ketolysis, the available acetoacetate is directlyincorporated into the TCA cycle and does not need to be initiallyoxidized by an NAD⁺ molecule. During endogenous ketosis (e.g., as aresult of fasting), the use of these NAD⁺ molecules to convertbeta-hydroxybutyrate to acetoacetate in peripheral tissues (ketolysis)is essentially balanced by the countervailing generation of NAD⁺molecules to convert acetoacetate to beta-hydroxybutyrate in the liver(ketogenesis).

However, when a user is supplementing with exogenousbeta-hydroxybutyrate, the use of NAD⁺ in the peripheral tissues is notbalanced in the same way by the generation of NAD⁺ in the liver.Supplementation of exogenous beta-hydroxybutyrate therefore creates anincrease in NAD⁺ demand on the user. Low levels of NAD⁺ are associatedwith aging and declining mitochondrial function. See, for example,Shin-ichiro Imai and Leonard Guarente, “NAD⁺ and Sirtuins in Aging andDisease,” Trends Cell Biol. 2014 Aug. 24(8), 464-471; Massudi H et al.,“Age-associated changes in oxidative stress and NAD⁺ metabolism in humantissue,” PLoS One, 2012, 7(7): e42357; Carlos Canto and Johan Auwerx,“Targeting Sirtuin 1 to Improve Metabolism: All you Need is NAD⁺?”Pharm. Rev. January 2012, 64(1) 166-187. In addition, low NAD⁺ relativeto NADH can set in motion some of the same physiological responses tolow NAD⁺ associated with low oxygen levels, even if actual oxygen levelsare accurate. See Gomes A P et al. “Declining NAD(+) induces apseudohypoxic state disrupting nuclear-mitochondrial communicationduring aging” Cell, 2013 Dec. 19, 155(7).

An exogenous ketogenic composition with an increased proportion ofacetoacetate relative to beta-hydroxybutyrate can therefore reduce thedepletion of NAD⁺ as compared to a composition having higher levels ofbeta-hydroxybutyrate. Compositions described herein include effectivelevels of acetoacetate in combination with beta-hydroxybutyrate in orderto achieve these benefits.

In general, beta-hydroxybutyrate is the primary “energy” ketone body,and having too high of a ratio of acetoacetate to beta-hydroxybutyratemay restrict the ability to obtain a desired energy boost. In somecases, excessive acetoacetate can also introduce undesirable effects.Referring again to FIG. 1 , an amount of acetoacetate circulating in theblood will spontaneously convert to CO₂ and acetone. High levels ofacetone can be undesirable. Elevated acetone levels can, for example,represent inefficient use of energy by indicating that acetoacetate isnot being converted to beta-hydroxybutyrate or being appropriately usedin the TCA cycle. Further, although the human body is typically able tomanage normal ketosis-related acetone levels, physiologically clearingexcess acetone can be taxing on the liver. In addition to these primaryphysiological impacts, excess acetone an also cause unpleasant “ketobreath.” Exogenous beta-hydroxybutyrate supplementation minimizesacetone generation because beta-hydroxybutyrate is typically notconverted into acetoacetate until reaching the peripheral tissues whereit is used.

For these reasons, the benefits of increasing the levels of acetoacetaterelative to beta-hydroxybutyrate must be balanced against thedetrimental effects of excessive acetoacetate. In one embodiment, aketogenic composition includes a combination of beta-hydroxybutyrate andacetoacetate, with the acetoacetate being included in an amount that isat least about 10%, at least about 20%, at least about 30%, or at leastabout 40% w/w of the beta-hydroxybutyrate and acetoacetate mixture.

At the same time, an optimized balance of beta-hydroxybutyrate andacetoacetate is typically where acetoacetate component is limited to nomore than about 45% of the beta-hydroxybutyrate and acetoacetatemixture. In other words, an optimized weight ratio ofbeta-hydroxybutyrate to acetoacetate may be about 19:1, about 16:1,about 14:1, about 12:1, about 9:1, about 6:1, about 4:1, about 3:1,about 7:3, about 1.5:1, about 1.22:1, and ranges defined by theseratios. Formulations having these ratios beneficially ensure that thereis sufficient acetoacetate in proportion to the beta-hydroxybutyrate toprovide the effective ketogenic properties described herein withoutcausing the detrimental effects associated with excess acetoacetate.Regulating the amount of each separate ketone body componentbeneficially allows for tailored compositions that are optimized forparticular needs or preferences. As described in more detail below, therelative amounts of beta-hydroxybutyrate and acetoacetate may beadjusted and optimized based on a subject's age, health, activity level,desired dosage regimen, and/or liver sensitivity, for example.

In general, subjects that may be deficient in NAD+, such as more elderly(e.g., those over 55, those over 60, those over 65, or those over 70) orinfirm people, may benefit from higher relative amounts of acetoacetate,such as between about 25% to about 45% acetoacetate, or about 30% toabout 45% acetoacetate, or about 35% to about 45% acetoacetate of thebeta-hydroxybutyrate and acetoacetate mixture. In addition, thecompositions disclosed herein may contain supplemental NAD+.

Similarly, subjects that are not deficient in NAD+, such as healthier,younger people, may benefit from lower relative amounts of acetoacetate,such as between about 5% to about 25% acetoacetate, or about 8% to about22% acetoacetate, or about 10% to about 20% acetoacetate of thebeta-hydroxybutyrate and acetoacetate mixture.

The ketogenic compositions described herein may be provided within adosage regimen effective for inducing and sustaining ketosis. Forexample, the combined beta-hydroxybutyrate and acetoacetate mass in adaily dose may range from about 0.5 gram to about 50 grams, or about0.75 gram to about 25 grams, or about 1 gram to about 15 grams, or about1.5 grams to about 12 grams. The daily dose may be provided as a singledaily dose or as a multiple dose (e.g., 2, 3, or 4 times daily).

The beta-hydroxybutyrate may be provided as the free acid, as a salt, asa mixed salt, as an ester, or as explained in greater detail below, as a“stacked” combination thereof. When provided in salt form,beta-hydroxybutyrate salts may include sodium, potassium, calcium,magnesium, or suitable transition metal (e.g., zinc, iron, molybdenum,or selenium) as cations, for example. Some embodiments may additionallyor alternatively include cations as one or more amino acids or otherorganic compounds that have a net positive charge at the pH at which thebeta-hydroxybutyrate salts are produced. Suitable amino acids for thispurpose can include amino acids that contain more than one amine groupcapable of being protonated to form a compound having a net positivecharge, which can provide the counter cation for beta-hydroxybutyrateanion. Examples include arginine, lysine, leucine, iso-leucine,histidine, ornithine, citrulline, L-glutamine, or other suitable aminoacids or metabolites of amino acids (e.g., creatine).

In some embodiments, a ketogenic composition may also include otherketone body precursors, such as one or more medium chain fatty acids orone or more mono-, di-, or triglycerides of one or more medium chainfatty acids. Including one or more medium chain fatty acids, or a mono-,di-, or triglyceride of one or more medium chain fatty acids can providean additional source for the production of ketone bodies independent ofthe beta-hydroxybutyrate or acetoacetate. In order words, thebeta-hydroxybutyrate and acetoacetate compounds promote more rapidachievement of ketosis in the body while the medium chain fatty acid ora mono-, di-, or triglyceride of a medium chain fatty acid helps sustainthe body in a state of ketosis once the exogenous beta-hydroxybutyrateand acetoacetate molecules have already been consumed by the body.Including at least one of MCT, medium chain fatty acid, or mono-, di-,or triglyceride of a medium chain fatty acid can help sustain ketosisover a longer period of time without having to provide more exogenousbeta-hydroxybutyrate and acetoacetate.

The at least one medium chain fatty acid has from 6 to 12 carbons,preferably from 8 to 10 carbons. Compositions and methods related to thecombination of beta-hydroxybutyrate with a medium chain fatty acid, orester thereof, are disclosed in U.S. Pat. No. 9,138,420, which patent isincorporated herein by this reference in its entirety.

In addition to or instead of the one or more medium chain fatty acids orone or more mono-, di-, or triglycerides of one or more medium chainfatty acids, ketogenic compositions may include one or more short and/orlong chain fatty acids or one or more mono-, di-, or triglycerides ofone or more short and/or long chain fatty acids. Short chain fatty acidstypically have fewer than 6 carbons, and long chain fatty acidstypically have more than 12 carbons.

Examples and sources of the medium chain fatty acid, or an ester thereofsuch as a medium chain triglyceride, include coconut oil, coconut milkpowder, fractionated coconut oil, palm oil, palm kernel oil, caprilicacid, isolated medium chain fatty acids, such as isolated hexanoic acid,isolated octanoic acid, isolated decanoic acid, medium chaintriglycerides either purified or in natural form such as coconut oil,and ester derivatives of the medium chain fatty acids ethoxylatedtriglyceride, enone triglyceride derivatives, aldehyde triglyceridederivatives, monoglyceride derivatives, diglyceride derivatives, andtriglyceride derivatives, and salts of the medium chain triglycerides.Ester derivatives optionally include alkyl ester derivatives, such asmethyl, ethyl, propyl, butyl, hexyl, etc.

Notwithstanding the foregoing, there is a practical limit to how muchMCT or other medium chain fatty acid source an individual can take, withsome individuals having lower tolerance for MCT or other medium chainfatty acid sources (e.g., they may cause gastrointestinal issues).

In some embodiments, the ketogenic composition may be provided as asolid or powder form. Solid or powder ketogenic compositions may includeone or more additional components configured to lower the hygroscopicityof the composition. For example, various anticaking agents, flow agents,and/or moisture absorbers, in types and amounts that are safe forconsumption, may be included. Such additional components may include oneor more of an aluminosilicate, ferrocyanide, carbonate or bicarbonatesalt, silicate (e.g., sodium or calcium silicate), phosphate salt (e.g.,tricalcium phosphate), talcum, powdered cellulose, and the like.

In alternative embodiments, the ketogenic composition may be provided asa liquid, such as in the form of a shot or mouth spray for fast deliveryand absorption, or as a gel. Liquid or gel forms may include one or morecarriers, such as water, ethanol, glycerin, propylene glycol, 1,3-propandiol, and the like, into which thebeta-hydroxybutyrate/acetoacetate compounds are dissolved or dispersed.The composition may include flavoring agents that help mask the somewhatpoor taste of beta-hydroxybutyrate compounds. These flavoring agents mayinclude essential oils, such as peppermint, natural and artificialsweeteners, and other flavorants known in the art.

The ketogenic composition may include one or more supplements known inthe art, such as vitamins, minerals, and caffeine or other stimulants.For example, the ketogenic composition may further comprise vitamin D3,such as in an amount of about 5 μg to about 200 μg, or about 10 μg toabout 100 μg, or about 15 μg to about μg, or in an amount of about 200IU to about 8000 IU, or about 400 IU to about 4000 IU, or about 600 IUto about 3000 IU. Caffeine may be included in an amount of about 10 mgto about 250 mg, or about 25 mg to about 170 mg, or about 40 mg to about120 mg.

III. Stacking Different Forms of Ketone Bodies

As described above, the exogenous ketone bodies described herein may beprovided in three general forms: 1) salt form, 2) ester form, and 3)free acid form (i.e., beta-hydroxybutyric acid or acetoacetic acid).Beta-hydroxybutyric acid can be provided as the R-enantiomer,S-enantiomer, racemic mixture, or enriched with the R- or S-enantiomer.The compositions described herein may be provided in any one of theseforms or as a “stacked” mixture combining at least two of these forms.

Each of the different forms has its own properties and its own potentialbenefits and limitations. For example, ester forms ofbeta-hydroxybutyrate or acetoacetate typically have poor organolepticproperties relative to the other forms. In addition, ester forms ofbeta-hydroxybutyrate or acetoacetate are often described as having apungent taste and/or smell.

Salt forms of beta-hydroxybutyrate or acetoacetate are generallyconsidered to taste better than ester forms. However, administration ofclinically or dietetically effective doses of exogenous ketone bodies insalt form inherently requires administration of relatively high levelsof the corresponding cations. Sodium, for example, is often used as thecation in ketone body salts, and high levels of sodium have well-knownnegative health effects. Excessive amounts of potassium and calciumshould also be avoided. Although different salts having differentcations may be mixed to dilute the impact of a single cation, it canstill be difficult to provide effective amounts of beta-hydroxybutyrateand/or acetoacetate without upsetting the electrolyte balance in thesubject/patient.

The free acid forms may also be utilized. However, becausebeta-hydroxybutyric acid has a pKa of 4.70, it deprotonates and producesH⁺ at physiological pH. Similarly, acetoacetic acid has a pKa of 3.59and likewise deprotonated and produces H⁺ at physiological pH. Theresulting excess acidity can cause undesirable side effects includingcausing or aggravating gastrointestinal issues such as ulcers or reflux.

The free acid form of acetoacetate is the least stable form (meaningthat it can decompose to acetone and carbon dioxide), with the salt formbeing somewhat more stable and the ester form being significantly morestable. The acid form has a half-life of 140 minutes at 37° C. in water,whereas the basic form (the anion in a salt form) has a half-life of 130hours. That is, it decomposes about 55 times more slowly. Esters are farmore stable and can persist for weeks, months, or years depending onstorage conditions.

Combining different forms of exogenous ketone bodies can beneficiallylimit the occurrence and/or severity of these undesirable side-effectsand/or can permit administration of higher doses of exogenous ketonebodies. For example, a ketone body stack can deliver the same amount ofexogenous ketones as a single form without causing the same occurrenceand/or severity of side-effects. Likewise, a combined form can deliver agreater amount of exogenous ketones than a single form before reachingsimilar occurrence and/or severity of side-effects.

This is schematically illustrated in FIGS. 2A and 2B. FIG. 2A showsdifferent exogenous ketone doses when using a single form (formulations1-3), a double stack (formulations 4-6), and a triple stack (formulation7). Although individual tolerances may vary and the illustrated dosesare therefore exemplary only, a typical subject will want to avoidexcessive amounts of any single form of exogenous ketones in order toavoid the corresponding side effects.

Accordingly, stacking different forms of exogenous ketones allows forgreater delivery of exogenous ketones in a dose and/or allows for ahigher dosing frequency as compared to use of the single form. Forexample, different forms of exogenous ketones may be stacked in a singledose to allow for greater amounts of exogenous ketones in the dose,and/or different forms of exogenous ketones may be taken in differentdoses throughout the day to allow for greater dosing frequency and thushigher overall daily delivery of exogenous ketones.

A single dose of stacked ketones can also provide more sustained levelsof ketone bodies in the blood as compared to an otherwise similar amountprovided in a single form. For example, a stacked formulation can betailored to provide a more preferable release profile, such as one thatcombines the benefits of more rapid onset with the benefits of a moreextended release, and/or one that provides an overall greaterpharmacokinetic area under the curve (AUC).

FIG. 2B shows expected relative severity of undesirable side-effectsresulting from treatment with various formulations of exogenous ketones,including stacked formulations. The triple stack formulation comprisingeach of 1) a salt form of an exogenous ketone, 2) an ester form of anexogenous ketone, and 3) a free acid form of an exogenous ketone isexpected to allow for administration of a greater amount of exogenousketones and/or to have reduced side-effects as compared to a doublestack comprising only two such forms of exogenous ketones. Both thetriple stack and the double stack are likewise expected to allow foradministration of a greater amount of exogenous ketones and/or to havereduced side-effects as compared to a single form comprising only oneform of exogenous ketone.

In other words, for a given dose of exogenous ketones, the triple stackcan be formulated to cause less 1) organoleptic side-effects, 2)electrolyte imbalance side-effects, and/or 3) acidity side-effects ascompared to the double stack or single form. For example, a single formketones body ester may have a threshold dosage that the typical userwill not exceed because of the negative organoleptic side-effects, asingle form ketone body salt may have a threshold dosage limited by therecommended dietary limits of the electrolytes administered with thesalt, and a single form ketone body free acid may have a thresholddosage that the typical user will not exceed because of the negativeeffects of acidity. The stacked forms of exogenous ketones, and inparticular the exogenous ketone triple stack, allows for supplementationof greater amounts of exogenous ketones without passing any of theseparate thresholds related to organoleptic, electrolyte, or acidityside-effects.

In some embodiments, a beta-hydroxybutyrate stack includes at least twoof: (i) one or more exogenous ketone salts; (ii) one or more exogenousketone esters; and (iii) an exogenous ketone body acid(beta-hydroxybutyric acid and/or acetoacetic acid). For example, anexogenous ketone double stack may include at least two of components(i), (ii), and (iii) each provided at about 2% to about 98%, or about 5%to about 95%, or about, 10% to about 90%, or about 20% to about 80%, orabout 30% to about 70%, or about 40% to about 60% on a molar basis ofthe ketone body component.

In some embodiments, a ketone body triple stack includes a ketone bodyester at about 2% to about 96%, or about 5% to about 90%, or about 10%to about 80%, or about 20% to about 60% on a molar basis of the ketonebody component, includes a ketone body salt at about 2% to about 96%, orabout 5% to about 90%, or about 10% to about 80%, or about 20% to about60% on a molar basis of the ketone body component, and includes a freeacid form at about 2% to about 96%, or about 5% to about 90%, or about10% to about 80%, or about 20% to about 60% on a molar basis of theketone body component. In some embodiments, a triple stack includes eachof the three carrier component forms in substantially equal amounts on amolar basis of the ketone body component.

A ketone body stack may also provide a more beneficial digestive releaseprofile. Each of the different carrier component forms may interactsomewhat differently upon ingestion. For example, the free acid form maybe readily delivered to the bloodstream as a usable ketone body, whereasketone bodies from salt forms may in general take slightly longer toreach the bloodstream depending on the solubility characteristics of theparticular salt or salt mixture utilized, and ester forms may in generaltake the longest to reach the bloodstream depending on how rapidly theester bond undergoes hydrolysis. Thus, a stacked formulation can betailored to provide a more preferable release profile, such as one thatcombines the benefits of more rapid onset with the benefits of a moreextended release, and/or one that provides an overall greaterpharmacokinetic area under the curve (AUC).

This is illustrated in FIG. 3 , which compares expected release profilesof keto stack compositions (e.g., comprising each of the free acid,salt, and ester forms) to each of the free acid, salt, and ester singleforms. Because the keto stack compositions are able to provide moreoverall exogenous ketone bodies, and because they are provided in aplurality of different forms with different release characteristics, theoverall release profile is extended and provides a larger AUC.

FIG. 3 also illustrates how a release profile may be adjusted byutilizing different relative amounts of S-beta-hydroxybutyrate andR-beta-hydroxybutyrate. As illustrated, the beta-hydroxybutyrate in the“R Stack” is substantially comprised of R-beta-hydroxybutyrate, whilethe “R/S Stack” replaces some of the R-beta-hydroxybutyrate withS-beta-hydroxybutyrate to flatten and extend the release profile.

Given that there are three separate “carrier component” forms and twodifferent “ketone body component” types, there are multiple keto stackcombinations that may be formulated. As reproduced below, Table 1illustrates several exemplary stacked combinations having 2, 3, 4, 5, or6 different compound types making up the stack.

TABLE 1 Combo BHB BHB BHB ACAC ACAC ACAC No. Salts Ester Acid Salt EsterAcid 2-part stacks 1 X X 2 X X 3 X X 4 X X 5 X X 6 X X 7 X X 8 X X 9 X X10 X X 11 X X 12 X X 13 X X 14 X X 15 X X 3-part stacks 16 X X X 17 X XX 18 X X X 19 X X X 20 X X X 21 X X X 22 X X X 23 X X X 24 X X X 25 X XX 26 X X X 4-part stacks 27 X X X X 28 X X X X 29 X X X X 30 X X X X 31X X X X 32 X X X X 33 X X X X 34 X X X X 35 X X X X 5-part stacks 36 X XX X X 37 X X X X X 38 X X X X X 39 X X X X X 40 X X X X X 6-part stack41 X X X X X X

IV. Administration

Ketogenic compositions described herein may be administered to a subjectin therapeutically effective dosages and/or in frequencies to induce orsustain ketosis. The combined beta-hydroxybutyrate and acetoacetate massin a daily dose may range from about 0.5 gram to about 50 grams, orabout 0.75 gram to about 25 grams, or about 1 gram to about 15 grams, orabout 1.5 grams to about 12 grams.

In some embodiments, the compositions may further include one or moremedium chain fatty acids, fatty acid esters, or mono-, di- ortriglycerides of medium chain fatty acids in order to provide anadditional source of ketone bodies for sustaining ketosis for a longerperiod of time compared to if just the beta-hydroxybutyrate/acetoacetatecombination were used by itself. In some embodiments, the composition ispreferably administered such that the ratio ofbeta-hydroxybutyrate/acetoacetate to medium chain fatty acid (or esterthereof) ranges from about 4:1 to about 1:4, or from about 2:1 to about1:2, or from about 1.5:1 to about 1:1.5.

In alternative embodiments, the compositions may further include one ormore short and/or long chain fatty acids, fatty acid esters, or mono-,di- or triglycerides of short and/or long chain fatty acids in order toprovide an additional source of ketone bodies for sustaining ketosis. Insome embodiments, the composition is preferably administered such thatthe ratio of beta-hydroxybutyrate/acetoacetate to medium, short and/orlong chain fatty acid (or ester thereof) ranges from about 4:1 to about1:4, or from about 2:1 to about 1:2, or from about 1.5:1 to about 1:1.5.

In some embodiments, the subject preferably follows a ketogenic dietthat restricts intake of carbohydrates and protein during the period ofadministration of the composition. In one example embodiment, thesubject may restrict the dietary intake to a ratio of about 65% fat,about 25% protein, and about 10% carbohydrates. The resultingtherapeutic ketosis provides a rapid and sustained keto-adaptation as ametabolic therapy for a wide range of metabolic disorders, and providesnutritional support for therapeutic fasting, weight loss, andperformance enhancement. As such, the composition is typicallyadministered once per day, twice per day, or three times per day to asubject desiring to promote and/or sustain a state of ketosis.

In a preferred embodiment, a ketogenic composition is administered viaoral administration of the composition in a solid, powdered form orliquid, such as in a powdered mixture (e.g., powder filled gelatincapsules), hard-pressed tablets, or other oral administration routeknown to those skilled in the art.

In some embodiments, multiple doses of the composition are administered.The frequency of administration of the composition can vary depending onany of a variety of factors, such as timing of treatment from previoustreatments, objectives of the treatment, and the like. The duration ofadministration of the composition (e.g., the period of time over whichthe agent is administered), can vary depending on any of a variety offactors, including subject response, desired effect of treatment,etcetera.

The amount of the composition to be administered can vary according tofactors such as the degree of susceptibility of the individual, the age,sex, and weight of the individual, idiosyncratic responses of theindividual, and the like. The “therapeutically effective amount” is thatamount necessary to promote a therapeutically effective result in vivo(i.e., therapeutic ketosis). In accordance with the present disclosure,a suitable single dose size is a dose that is capable of preventing oralleviating (reducing or eliminating) a symptom in a patient whenadministered one or more times over a suitable time period.

The amount of composition administered will depend on potency,absorption, distribution, metabolism, and excretion rates of thecomposition components, the method of administration, and the particulardisorder being treated, as well as other factors known to those of skillin the art. The dose should be sufficient to affect a desirableresponse, such as a therapeutic or prophylactic response against aparticular disorder or condition, taking into account the severity ofthe condition to be alleviated. The compounds may be administered onceover a given time period (e.g., once per day), or may be divided andadministered over intervals of time. It is to be understood thatadministration may be adjusted according to individual need andprofessional judgment of a person administrating or supervising theadministration of the compositions.

V. Examples

The following is a description of exemplary combinedbeta-hydroxybutyrate/acetoacetate compositions useful for inducingand/or sustaining a ketogenic state in a subject to which they areadministered. It should be appreciated that the beta-hydroxybutyrate andacetoacetate compounds described in the examples can be in the form ofsalts, esters, dimers, trimers, oligomers, and polymers, as discussedherein. The compositions can also be combined with medium chain fattyacids, esters, glycerides, and other supplements as disclosed herein toprovide a desired level of elevated ketone bodies and other effects.

Example 1

A combined beta-hydroxybutyrate/acetoacetate composition is prepared bymixing beta-hydroxybutyrate with acetoacetate. The acetoacetate is addedat 10% the weight of the beta-hydroxybutyrate/acetoacetate mixture.Compared to a similar dosage of beta-hydroxybutyrate withoutacetoacetate, the combined beta-hydroxybutyrate/acetoacetate compositionlimits the reduction of available NAD⁺ in the subject. At the same time,the amount of acetoacetate is not so high as to cause unwanted effectsassociated with high levels of acetone in the blood.

The beta-hydroxybutyrate/acetoacetate composition is readilyadministered as a ketogenic composition, such as in powder, liquid orgel form as a dietary supplement mixed with food or drink, in the formof one or more capsules or tablets, or in liquid form such as a mouthspray or energy shot.

Example 2

A combined beta-hydroxybutyrate/acetoacetate composition is prepared bymixing beta-hydroxybutyrate with acetoacetate. The acetoacetate is addedat 15% the weight of the beta-hydroxybutyrate/acetoacetate mixture.Compared to a similar dosage of beta-hydroxybutyrate withoutacetoacetate, the combined beta-hydroxybutyrate/acetoacetate compositionlimits the reduction of available NAD⁺ in the subject. At the same time,the amount of acetoacetate is not so high as to cause unwanted effectsassociated with high levels of acetone in the blood.

The beta-hydroxybutyrate/acetoacetate composition is readilyadministered as a ketogenic composition, such as in powder, liquid orgel form as a dietary supplement mixed with food or drink, in the formof one or more capsules or tablets, or in liquid form such as a mouthspray or energy shot.

Example 3

A combined beta-hydroxybutyrate/acetoacetate composition is prepared bymixing beta-hydroxybutyrate with acetoacetate. The acetoacetate is addedat 20% the weight of the beta-hydroxybutyrate/acetoacetate mixture.Compared to a similar dosage of beta-hydroxybutyrate withoutacetoacetate, the combined beta-hydroxybutyrate/acetoacetate compositionlimits the reduction of available NAD⁺ in the subject. At the same time,the amount of acetoacetate is not so high as to cause unwanted effectsassociated with high levels of acetone in the blood.

The beta-hydroxybutyrate/acetoacetate composition is readilyadministered as a ketogenic composition, such as in powder, liquid orgel form as a dietary supplement mixed with food or drink, in the formof one or more capsules or tablets, or in liquid form such as a mouthspray or energy shot.

Example 4

A combined beta-hydroxybutyrate/acetoacetate composition is prepared bymixing beta-hydroxybutyrate with acetoacetate. The acetoacetate is addedat 25% the weight of the beta-hydroxybutyrate/acetoacetate mixture.Compared to a similar dosage of beta-hydroxybutyrate withoutacetoacetate, the combined beta-hydroxybutyrate/acetoacetate compositionlimits the reduction of available NAD⁺ in the subject. At the same time,the amount of acetoacetate is not so high as to cause unwanted effectsassociated with high levels of acetone in the blood.

The beta-hydroxybutyrate/acetoacetate composition is readilyadministered as a ketogenic composition, such as in powder, liquid orgel form as a dietary supplement mixed with food or drink, in the formof one or more capsules or tablets, or in liquid form such as a mouthspray or energy shot.

Example 5

A combined beta-hydroxybutyrate/acetoacetate composition is prepared bymixing beta-hydroxybutyrate with acetoacetate. The acetoacetate is addedat 30% the weight of the beta-hydroxybutyrate/acetoacetate mixture.Compared to a similar dosage of beta-hydroxybutyrate withoutacetoacetate, the combined beta-hydroxybutyrate/acetoacetate compositionlimits the reduction of available NAD⁺ in the subject. At the same time,the amount of acetoacetate is not so high as to cause unwanted effectsassociated with high levels of acetone in the blood.

The beta-hydroxybutyrate/acetoacetate composition is readilyadministered as a ketogenic composition, such as in powder, liquid orgel form as a dietary supplement mixed with food or drink, in the formof one or more capsules or tablets, or in liquid form such as a mouthspray or energy shot.

Example 6

A combined beta-hydroxybutyrate/acetoacetate composition is prepared bymixing beta-hydroxybutyrate with acetoacetate. The acetoacetate is addedat 35% the weight of the beta-hydroxybutyrate/acetoacetate mixture.Compared to a similar dosage of beta-hydroxybutyrate withoutacetoacetate, the combined beta-hydroxybutyrate/acetoacetate compositionlimits the reduction of available NAD⁺ in the subject. At the same time,the amount of acetoacetate is not so high as to cause unwanted effectsassociated with high levels of acetone in the blood.

The beta-hydroxybutyrate/acetoacetate composition is readilyadministered as a ketogenic composition, such as in powder, liquid orgel form as a dietary supplement mixed with food or drink, in the formof one or more capsules or tablets, or in liquid form such as a mouthspray or energy shot.

Example 7

A combined beta-hydroxybutyrate/acetoacetate composition is prepared bymixing beta-hydroxybutyrate with acetoacetate. The acetoacetate is addedat 40% the weight of the beta-hydroxybutyrate/acetoacetate mixture.Compared to a similar dosage of beta-hydroxybutyrate withoutacetoacetate, the combined beta-hydroxybutyrate/acetoacetate compositionlimits the reduction of available NAD⁺ in the subject. At the same time,the amount of acetoacetate is not so high as to cause unwanted effectsassociated with high levels of acetone in the blood.

The beta-hydroxybutyrate/acetoacetate composition is readilyadministered as a ketogenic composition, such as in powder, liquid orgel form as a dietary supplement mixed with food or drink, in the formof one or more capsules or tablets, or in liquid form such as a mouthspray or energy shot.

Example 8

A combined beta-hydroxybutyrate/acetoacetate composition is prepared bymixing beta-hydroxybutyrate with acetoacetate. The acetoacetate is addedat 45% the weight of the beta-hydroxybutyrate/acetoacetate mixture.Compared to a similar dosage of beta-hydroxybutyrate withoutacetoacetate, the combined beta-hydroxybutyrate/acetoacetate compositionlimits the reduction of available NAD⁺ in the subject. At the same time,the amount of acetoacetate is not so high as to cause unwanted effectsassociated with high levels of acetone in the blood.

The beta-hydroxybutyrate/acetoacetate composition is readilyadministered as a ketogenic composition, such as in powder, liquid orgel form as a dietary supplement mixed with food or drink, in the formof one or more capsules or tablets, or in liquid form such as a mouthspray or energy shot.

Example 9

A combined beta-hydroxybutyrate/acetoacetate composition is prepared bymixing beta-hydroxybutyrate with acetoacetate. The acetoacetate is addedat 5% the weight of the beta-hydroxybutyrate/acetoacetate mixture.Compared to a similar dosage of beta-hydroxybutyrate withoutacetoacetate, the combined beta-hydroxybutyrate/acetoacetate compositionreduces depletion of available NAD⁺ in the subject. At the same time,the amount of acetoacetate low and limits unwanted effects associatedwith high levels of acetone in the blood.

The beta-hy droxy butyrate/aceto acetate composition is readilyadministered as a ketogenic composition, such as in powder, liquid orgel form as a dietary supplement mixed with food or drink, in the formof one or more capsules or tablets, or in liquid form such as a mouthspray or energy shot.

Example 10

Any of the foregoing examples is modified by combining the combinedbeta-hydroxybutyrate/acetoacetate composition with a dietetically orpharmaceutically acceptable carrier.

Example 11

Any of the foregoing examples is modified by combining the combinedbeta-hydroxybutyrate/acetoacetate composition with one or more mediumchain triglycerides and/or one or more medium chain fatty acids and/orone or more mono- or diglycerides of medium chain fatty acids.

Example 12

Any of the foregoing examples is modified by combining the combinedbeta-hydroxybutyrate/acetoacetate composition with one or more shortchain triglycerides and/or one or more short chain fatty acids and/orone or more mono- or diglycerides of short chain fatty acids.

Example 13

Any of the foregoing examples is modified by combining the combinedbeta-hydroxybutyrate/acetoacetate composition with one or more longchain triglycerides and/or one or more long chain fatty acids and/or oneor more mono- or diglycerides of long chain fatty acids.

Example 14

Any of the foregoing examples is modified by combining the combinedbeta-hydroxybutyrate/acetoacetate composition with one or moresupplements, such as vitamin D3, vitamins, minerals, and others known inthe art.

Example 15

Any of the foregoing examples is modified by combining the combinedbeta-hydroxybutyrate/acetoacetate composition with NAD⁺.

Example 16

Any of the foregoing examples is modified by combining the combinedbeta-hydroxybutyrate/acetoacetate composition with caffeine and/or otherstimulant(s) known in the art.

Example 17

Any of the foregoing examples is modified by combining two or moredifferent carrier component forms to form a stacked composition.

The present invention may be embodied in other specific forms withoutdeparting from its spirit or essential characteristics. The describedembodiments are to be considered in all respects only as illustrativeand not restrictive. The scope of the invention is, therefore, indicatedby the appended claims rather than by the foregoing description. Allchanges which come within the meaning and range of equivalency of theclaims are to be embraced within their scope.

1. A composition for administering ketone bodies to a subject,comprising: at least one beta-hydroxybutyrate compound selected from thegroup consisting of beta-hydroxybutyrate salt and beta-hydroxybutyratefree acid; and at least one acetoacetate compound selected from thegroup consisting of acetoacetate salt and acetoacetate free acid.
 2. Thecomposition of claim 1, wherein the composition comprises: about 55% toabout 95% by weight of the at least one beta-hydroxybutyrate compound;and about 5% to about 45% by weight of the at least one acetoacetatecompound.
 3. The composition of claim 1, wherein the at least onebeta-hydroxybutyrate compound comprises a plurality ofbeta-hydroxybutyrate salts selected from the group consisting of sodiumbeta-hydroxybutyrate, potassium beta-hydroxybutyrate, magnesiumbeta-hydroxybutyrate, calcium beta-hydroxybutyrate, and amino acidbeta-hydroxybutyrate.
 4. The composition of claim 1, wherein the atleast one acetoacetate compound comprises a plurality of acetoacetatesalts selected from the group consisting of sodium acetoacetate,potassium acetoacetate, magnesium acetoacetate, calcium acetoacetate,and amino acid acetoacetate.
 5. The composition of claim 1, furthercomprising at least one ketone body ester selected from the groupconsisting of beta-hydroxybutyrate esters and acetoacetate esters. 6.The composition of claim 5, wherein the ketone body ester comprises atleast one of a mono-ester of ethanol, a mono-ester of 1-propanol, amono-ester of 1,3-propanediol, a di-ester of 1,3-propanediol, amono-ester of 1,3-butanediol, di-ester of 1,3-butanediol, a mono-esterof glycerin, a di-ester of glycerin, or a tri-ester of glycerin.
 7. Thecomposition of claim 1, wherein the composition is provided as abeverage.
 8. The composition of claim 1, wherein the composition isprovided as a mouth spray or energy shot.
 9. The composition of claim 1,wherein the composition is provided as a powder, liquid, gel,suspension, tablet, capsule, food product, food additive, beverageadditive, or food supplement.
 10. The composition of claim 1, whereinthe composition is free of medium chain fatty acids.
 11. A kit foradministering ketone bodies to a subject, comprising: a compositioncomprising at least one beta-hydroxybutyrate compound selected from thegroup consisting of beta-hydroxybutyrate salt and beta-hydroxybutyratefree acid and at least one acetoacetate compound selected from the groupconsisting of acetoacetate salt and acetoacetate free acid; a containerin which the composition is placed, wherein the container is one or moreof a carton, a box, a can, a jar, a bag, a pouch, a jug, or a keg; and ameasuring device configured to hold therein a unit dose, or fractionthereof, of the composition, wherein a unit dose of the compositioncontains about 0.5 g to about 50 g of combined beta-hydroxybutyrate andacetoacetate salts, wherein the measuring device is one or more of acup, a scoop, a syringe, a spoon, or a spatula.
 12. The kit of claim 11,wherein the composition comprises: about 55% to about 95% by weight ofthe at least one beta-hydroxybutyrate compound; and about 5% to about45% by weight of the at least one acetoacetate compound.
 13. The kit ofclaim 11, wherein: the at least one beta-hydroxybutyrate compoundcomprises a plurality of beta-hydroxybutyrate salts selected from thegroup consisting of sodium beta-hydroxybutyrate, potassiumbeta-hydroxybutyrate, magnesium beta-hydroxybutyrate, calciumbeta-hydroxybutyrate, transition metal beta-hydroxybutyrate, and aminoacid beta-hydroxybutyrate.
 14. The kit of claim 11, wherein the at leastone acetoacetate compound comprises a plurality of acetoacetate saltsselected from the group consisting of sodium acetoacetate, potassiumacetoacetate, magnesium acetoacetate, calcium acetoacetate, transitionmetal acetoacetate, and amino acid acetoacetate.
 15. The kit of claim11, wherein the composition is free of medium chain fatty acids.
 16. Acomposition for administering ketone bodies to a subject, thecomposition comprising: at least one beta-hydroxybutyrate compoundselected from the group consisting of beta-hydroxybutyrate salt andbeta-hydroxybutyrate free acid; at least one acetoacetate compoundcomprising one or more acetoacetate salt and optionally acetoacetatefree acid.
 17. The composition of claim 16, further comprising one ormore ketone body esters selected from the group consisting ofbeta-hydroxybutyrate esters and acetoacetate esters.
 18. The compositionof claim 16, wherein the at least one beta-hydroxybutyrate compoundcomprises a plurality of beta-hydroxybutyrate salts selected from thegroup consisting of sodium beta-hydroxybutyrate, potassiumbeta-hydroxybutyrate, magnesium beta-hydroxybutyrate, and calciumbeta-hydroxybutyrate; and
 19. The composition of claim 16, wherein theat least one acetoacetate compound comprises a plurality of acetoacetatesalts selected from the group consisting of sodium acetoacetate,potassium acetoacetate, magnesium acetoacetate, and calciumacetoacetate.
 20. The composition of claim 16, wherein the compositioncomprises: about 55% to about 95% by weight of the at least onebeta-hydroxybutyrate compound; and about 5% to about 45% by weight ofthe at least one acetoacetate compound.